In talking with the reporter for this story, I did cite many data points of how Anthem Blue Cross was the most aggressive opponent of state health reform efforts, both small and large, from including maternity coverage as a basic benefit to the universal coverage proposals of Governor Schwarzenegger to the legislation to set up a California exchange under the Affordable Care Act. They lobbied against these proposals, they funded ads and other opposition, they used their whole influence. They profited under the old rules, aggressively denying people for pre-existing conditions and using risk selection and cherry picking and other tactics, and fought the change to a new set of rules.

Today, they are participating in the implementation of the ACA: they are a major insurer offered under Covered California, the state’s marketplace; they have more business as a Medicaid managed care plan.

I want to be clear: Anthem is still Anthem–they oppose further rate regulation, or many other needed improvements to our health system. But they now have to play by new rules. Maternity coverage was going to be a basic benefit regardless in 2014, and the political momentum was already there to do it sooner. There wasn’t much of a choice–they have the most to lose, especially as one of the biggest insurers in the state, especially in the individual insurance market. If they didn’t participate in the Exchange, that’s potentially a lot of lost business, and certainly a lost opportunity to grow their footprint. And in California, there’s little advantage to rail against Obamacare, where all statewide elected officers and over 2/3rds of the legislature support the ACA.

This willingness to play by the new rules (even if resisting added proposals) merits recognition. But with all these caveats, this evolution is not as much a “change of heart” as of strategy, a recognition of reality. But its indicative of why the Tea Party-inspired efforts of the GOP to repeal the ACA feels so distant here in California. If even the staunchest opponent in the insurance industry has come around to being part of a new set of rules, then we really aren’t going back. The question is when the politicians in DC get the memo.